HEALTH CARE SYSTEM IN CROATIA

Professor Miroslav Mastilica Andrija Štampar School of Public Health

University of Zagrebmmastil@snz.hr

Vanesa Benković, MA Public Healthvanesa@mediametar.hr

GENERAL/HEALTH DATA

Indicator Year Value

Population 2007 4.436 mil

% of population aged 0-14 years 2006 15.71%

% of population aged 65+ years 2006 17.03%

Population density 2007 78,4

Living in urban areas2003 59%

Important disadvantaged groupsRoma, unemployed, one parent

families, old retired people, PTSP

POVERTY (Eurostat) 2003 18%

Total health expenditure as % of GDP 2005 7,9%

Total social expenditure as % of GDP 2005 11,1%

Total social expenditure protection per head 2007 1.062 EUR

Nationality proportion2006

Croatian 93,3Serbian 3,6Others 2,3

Indicator Year Value

Live births per 1000 population 2006 9.33

Mortality rate 2007 11,8%

Life expectancy by gender maleLife expectancy by gender female

200772,3 total 75,8

79,2

Estimated infant mortality per 1000 live births 2004 6

Infant deaths per 1000 live births 2007 5,6

SDR, diseases of circulatory system, all ages per 100000

2006 417.73

SDR, malignant neoplasms, all ages per 100000 2006 210.24

Tuberculosis incidence per 100000 2007 20.88

Alcohol prevalence 2006 1.500 000 33%

Smoking prevalence 2006 27,4%

Hospital beds per 1000 2007 5,49

Physicians per 100000 2007 259.02

In-patient care admissions per 100 2007 16.47

 INDICATOR Croatia Austria Czech r. Slovenia Hungary EU 15

Life expectancy 75,44 79,7 76,19 77,58 73,02 78,53

Life expectancy  M 71,9 76,81 72,97 74,04 68,75 75,41

Life expectancy  F 78,92 82,37 79,32 80,93 77,23 81,56

Infant mortality rate 5,7 4,18 3,39 4,15 6,23 4,94

Cardiovascular 438,83 240,2 419,02 288,02 502,43 271,19

Ischaemia 167,93 111,65 177,51 80,2 261,33 102,83

Cancers and similar 212,6 165,81 217,46 196,96 237,44 179,16

Comparative health indicators, 2005 (Croatian Dpt for Public Health)

proportionproportion

POPULATION by sex & age

Education 2001

3

38

48

11no education

elementary

high school

university

Health costs as GDP %

9,4 10 11,2 9,6 8,6 8,2 8,3 7,9

0

5

10

15

1998 1999 2000 2001 2002 2003 2004 2005

Social costs as GDP %

19,1 19,3 18,316,6 16,8

14

16

18

20

2000 2001 2002 2003 2004

GDP annual growth rate trend

3 3,8 5,4 5 4,2 4,2 4,7 5,52,4

05

10

2000 2001 2002 2003 2004 2005 2006 2007 2008

GDP PPS

8200 8600 9300 9800 10600 11100 11700

0

5000

10000

15000

2000 2001 2002 2003 2004 2005 2006

GDP PPS INDEX EU 27= 100

49,2 50,3 52,3 54,3 55,85 56,6 58,3 61,1 63

0

10

20

30

40

50

60

70

2000 2001 2002 2003 2004 2005 2006 2007 2008

health insurance costs in mil HRK health insurance costs as BDP %

Absolute (left) and relative (right) costs of basic health insurance 1995-2005

Structure of health costs 1996-2005

Primary care, dentistry

Specialists

Orthopedics and similar

Birth and pregnancy compens

Pharmacotherapy

Hospital care

Sickness leave compens

  2005 2007

Total 19,3 19

Health 5,1 5,5

Social protection 14,2 13,4

Sickness disabled 2 2,3

Old age care 9,1 8,3

Family and children 1,8 1,7

Unemployment 0,4 0,3

Housing 0,01 0,01

Social exclusion 0,2 0,2

R&D 0,007 0,006

Other 0,3 0,4

Social costs structure

(revised BDP, GFS manual 2001)

  1998. 1999. 2000. 2001. 2002. 2003. 2004. 2005.

Total health costs 9,4 10 11,2 9,6 8,6 8,2 8,3 7,9

Croatian Health Insurance 8,4 9 9,8 8,4 7,4 7,2 7,2 6,8

CHI costs (without sickness andmaternal leave) 6,6 7,2 7,6 6,8 5,7 6 6,1 5,9

Private health cost (survey onhousehold expenditure) 1 1 1,3 1,1 1,2 1,1 1,2 1,1

Proportion of private in total health costs 13,2 13,1 14,7 14,4 17,6 15 16 15,6

Financial indicators of health systems (as GDP %)

• Roma population, make less than 1% of total population yet 13,56% of thema re dependant on social help care

• 2,7% of total population gets social help care, 5-10% are in counties with significant refugee returns

• Long term unemployed – more then 3%, for ¼ of them health costs are too high (twice higher than employed=

• One parent families – vulnerable groups

• shocking 62% of people older than 65 yrs, do not get pension income and live in poverty, compared to 19% of older than 65 yrs who get the pensions

• 2001. one fifth of population older than 65 yrs (around 131.414 persons) do not receive the full pension.

• 2007. there are 49.187 war veterans with disablement

• Health system is not “youth friendly”

Poverty and vulnerable groups

Problem 4 SE

countries

Other 15EU

countries

New EU members

Countries candidates Croatia

Hospital/doctor distance  9 2 6 26 12

Delay of appointment 19 7 14 27 22

Waiting at dispensary 20 7 15 29 17

Problems in access to health services

(% of persons claiming that the problem caused huge access issues)

Problem Total Income Q1 (lowest)

Income Q4 (highest) Q1/Q4

Hospital/doctor distance         

EU 15 4,1 5,4 2,3 2,3

New EU members 6,5 9,4 3,8 1,5

Croatia 12,8 26 3,9 6,7

Delay of appointment        

EU 15 11,1 12 7,9 1,5

New EU members 14,3 16,4 12,1 1,4

Croatia 23,3 32,8 20 1,6

Waiting at dispensary        

EU 15 11,3 11,9 8,7 1,4

New EU members 14,7 18,4 12,9 1,4

Croatia 18,3 25,6 15,5 1,7

Costs connected with treatment      

EU 15 8,2 9,9 4,5 2,2

New EU members 15,4 22,1 10,3 2,1

Croatia 20,3 38,1 8,7 4,4

Problems in access to health services

(% of persons claiming that the problem caused huge access issues)

The Health Care System

KEY ASPECTS

• Primary health care

• Universal access

• Continuity

• Comprehensive system

• Solidarity-based

HEALTH CARE SYSTEMORGANISATIONAL STRUCTURE 2008

County Government

MINISTRY OF HEALTH

CROATIAN INSTITUTE FOR HEALTH INSURANCE

Health centres 50

General hospitals 22

Special hospitals 31

Policlinics 321

Pharmacies 176

Nursing care institutions 156

Health resorts 7

Emergency care institutions 4

County public health institutes 22

University hospitals and clinics 14

State health institutes 6

Croatian Institute of Public Health

Private practices: 9713 4405 medical 4674 dental 438 pharmacies 112 nursing centers 84 laboraties

Insured persons

GOVERNMENT OF CROATIA

MINISTRY OF FINANCE

Health care System

• 2007:

• 5,49 beds per 1000 population

• 11.799 MDs

• 3265 stomatologists

• 2607 pharmacists

• 26,873.507 visits to PHC

• 7, 731.267 visits to specialists

• 636.450 hospitalizations

HEALTH CARE SYSTEM

FINANCING:

• Social health insurance 80%

• General taxation up to 18%

• Out-of pocket payments 2%

• Per capita expenditure USD 651

PRESENT PROBLEMS:

Lack of resources

Increasing co-payments by patients

Privatisation of services: Two tier system

Social inequalities in health and health care utilization

HEALTH CARE SYSTEM

HEALTH CARE SYSTEM REFORM

• CENTRALIZATION

• PRIVATISATION

• RATIONALIZING

• MARKETISATION

“Alice in the Wonderland”

HEALTH CARE REFORM IN CROATIA

• transformation of health services:

from SOCIAL GOODS to COMMODITIES

• /from PUBLIC to MARKET/

HEALTH CARE SYSTEM:

Health care reform Problems:

• reductions in patient’s benefits

• introduction of market mechanisms

• citizens as patients paying more and act as consumers

HEALTH CARE SYSTEM

GROUPS AT RISK:

• Low-income citizens

• Unemployed

• Large families/one parent families

• Elderly

• People living in remote areas

Policy recommendations:

• a clear national strategy on health !?

• Political independence !?

• Decentralisation !?

• positive discrimination !?

• progressive payment structure !?

HEALTH INEQUITIES IN CROATIA

• Inequalities in health

• Inequalities in health care utilization

• Inequalities in financing of health care services

Standardized mortality ratios (25-64) by socio professional group (Yugoslavia/Croatia, 1981)

Socio professional groups SMR

• Executives 16

• Professionals 75

• Clerks 53

• Services workers 60

• Industrial workers 132

• Peasants 116

HEALTH INEQUITIES IN CROATIA

Do you agree with the statement that:

‘some people in this country have easier access to healthcare services and receive better quality of care than others’?

YES

1989 65.8%1994 75.2%2000 82.3%

HEALTH INEQUITIES IN CROATIA

Self-perceived general health status by socioeconomic group (Zagreb health inequalities study 1990, N=433, p<.01 )

Social groups/Health Very Good Good Fair Bad

Executives 17.2 42.9 31.7 2.8

Professionals 25.0 40.0 37.1 3.3

Clerks 17.7 38.8 30.6 12.9

Skilled workers 21.2 23.8 34.6 15.9

Unskilled workers 13.3 16,7 53.3 16.7

Farmers 15.1 18.2 39.4 27.3

HEALTH INEQUITIES IN CROATIA

INEQUITIES IN HEALTH IN CROATIA 1994

11,3

23,3 24,3

41,146,03

31,75

12,79,52

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4

Quartiles of income

Sh

are

in

pe

rce

nt

% income % poor and very poor health

Table. Distribution by quartiles of direct payments for health care Croatia, 1994

Direct health care payments

Income quartileincome

proportion%

copaymentsproportion

%

other directpaymentsproportion

%

total direct paymentsproportion

%

Bottom 11.3 37.7 30.3 32.1

2nd 23.3 22.6 27.1 26.0

3rd 24.3 18.9 15.5 16.3

Top 41.1 20.8 27.2 25.6

% of total direct payments

24.7 75.3 100

Gini 0.226Concentration -0.136 -0.052 -0.073

Kakwani -0.362 -0.278 -0.299

Inequaities in Health care financing in Croatia

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

% of population

% o

f in

com

e a

nd

pa

yme

nts

g-inc g-pay

Lorenz curve for income (triangles) and the concentration curve of out-of-pocket payments (squares)

Inequity in h.c. finance

• Increase of co-payments and other direct payments

• considered a significant problem for lower income people

Inequity in h. c. finance

• Burden of out-of-pocket costs is not equally distributed among income groups – low income group paying about six times larger share of income paid by high income group

• Inequitable pattern of out-of-pocket health care payments

• Regressive health care financing system

Table. Self-perceived health status by income 2003 Croatian AdultHealth Survey N=11138

%

Health/INCOME low middle high

Excellent 13,8 29 57,3%

Very good 11,9 28 60,1

Good 25 33,8 41,2

Fair 32,7 35,7 31,6

Bad 51,1 30,8 18,1

p<0.001

Table. Self-perceived health status by education 2003Croatian Adult Health Survey N=11138

%

Health/Education low middle high

Excellent 2,4 9,9 12,0

Very good 5,1 20,5 30,1

Good 28,4 30,3 30,3

Fair 35,9 28,6 21.6

Bad 28.2 10,8 6.1

p<0.001

Visits to specialists, by income groups when controled by health status 2003 Croatian Adult Health

Survey N=11138

INCOME

POOR HEALTH

low middle high

Not visited 36,5 29,5 26,1

1-2 visits 26,3 22,9 26,1

3-4 visits 17,1 17,7 20,7

5-10 visits 12,7 16,3 13,0

10+ visits 7,4 13,5 14,1 p<0.001

Upitnik SF-36

• 8 različitih područja zdravlja:– Fizičko funkcioniranje (PF)– Ograničenja zbog fizičkog zdravlja (RP)– Tjelesni bolovi (BP)– Opće zdravlje (GH)– Vitalnost (VT)– Socijalno funkcioniranje (SF)– Ograničenja zbog emocionalnih problema (RE)– Psihičko zdravlje (MH)

20

30

40

50

60

70

80

90

100

Muškarci Žene

Zdravstvene nejednakosti prema spolu2003 Hrvatska zdravstvena anketa N=11138SF36 Dimenzije zdravlja

20

30

40

50

60

70

80

90

100

NSS SSS VŠS i VSS

Zdravstvene nejednakosti prema obrazovanju2003 Hrvatska zdravstvena anketa N=11138SF36 Dimenzije zdravlja

Dimenzije zdravlja Sjeverna HR Istočna HR

Južna HR

Zapadna HR

Središnja HR Grad Zagreb

M M M M M M

Fizičko funkcioniranje 72,2 66,5 73,0 68,2 67,3 70,2

Ograničenja zbog fizičkih poteškoća 65,1 57,8 67,1 69,9 58,2 60,4

Tjelesni bolovi 66,2 63,2 68,1 72,6 62,3 61,9

Opće zdravlje 58,6 52,3 58,0 59,3 54,1 51,6

Vitalnost / Energija 54,7 51,9 55,8 57,5 52,7 52,0

Socijalno funkcioniranje 74,9 72,0 76,3 77,4 74,3 73,3

Ograničenja zbog emocionalnih poteškoća 73,3 65,0 72,8 76,2 69,86 68,3

Psihičko zdravlje 64,7 60,2 64,9 65,6 63,1 61,7

Regionalne nejednakosti u zdravlju

Hrvatska zdravstvena anketa 2003, N=11138